Maudsley Family Based Therapy Explained – Part 1

The Maudsley approach is the leading family-based treatment for adolescents and children with Anorexia Nervosa. It is unique in that it utilizes parents and siblings in the recovery process, while providing short-term intervention that prioritises restoring nutritional health in the initial phase: a crucial advantage at a time when young bodies are still developing.

At BodyMatters we are proud to offer Maudsley-based treatment, with our Clinical Psychologist Christie Lomas specializing in this approach. Here Christie sheds light on why Maudsley is being hailed as the ‘gold standard’ treatment for Anorexia. Stay tuned for parts 2 and 3 of this blog, where Christie answers common questions asked by families and shares the thoughts of families that have undergone this approach.

By BodyMatters’ Clinical Psychologist, Christie Lomas

What is the Maudsley Approach?

The Maudsley approach or Family Based Treatment (FBT) originated from the Maudsley Hospital in London by a team of child and adolescent psychologists and psychiatrists who wanted to form an approach to prevent hospitalisation of a young person suffering with anorexia. The aim was to help parents to help their adolescent recover and return to normal adolescent development without an eating disorder.

What is the evidence for this approach?

Maudsley FBT is an evidence-based approach. Studies have demonstrated the efficacy of this approach with adolescents suffering with anorexia nervosa [1]. Within these studies, approximately two thirds of adolescent patients are recovered at the end of FBT while 75 – 90% achieved full weight recovery at five-year follow-up. Similar improvements in mood and psychological factors were also noted [2]. More recent studies have shown that most young people with anorexia need on average about 20 sessions over 6-12 months and that 80% are weight restored and have started or resumed menstruation by the end of Maudsley FBT [3]. Furthermore, a large randomised control trial in 2010 comparing FBT to Adolescent –Focused Individual Therapy (AFT) for adolescents with anorexia nervosa revealed FBT to be significantly superior to AFT at 6 and 12 month follow-ups after the end of treatment. Those with high obsessionality and other increased psychopathology associated with eating disorders were also shown to benefit more from FBT. Implementation of AFT did also lead to improvement, however FBT came out on top in terms of moving patients faster to achieve physical health [4]. Given the serious effect of anorexia on growth and development during adolescence in addition to the numerous other medical complications, treatments which move the adolescent quickly into remission should be considered above others.

FBT is best viewed as an intensive form of outpatient treatment which involves three distinct phases usually conducted within about 15-20 sessions over approximately 12 months.

Phase I: Weight restoration

During this phase, we talk about the medical complications involved with severe malnutrition, assess the family’s usual interactions, eating patterns and help the parents work together to re-feed their adolescent. Sometimes the young person can be distressed at first when their parents begin to take charge. Siblings play an important role by sympathising with this distress, without joining the parents in their more direct struggle against the anorexia. A family meal (where food is brought into the session) is conducted during this phase. This allows us to observe what tends to happen around food and gives us the opportunity to assist parents in helping their young person to eat a little more than he/she is prepared to.

We do not in any way blame the young person for the illness and its associated behaviours, but rather view these as being outside their control. The anorexia is seen as having taken control of the child and that he/she has little chance of fighting it on their own. Furthermore, in no way do we see that families are to blame for the development of anorexia, but rather view families as an invaluable resource essential for the successful treatment of anorexia.

Phase II: Returning control of eating back to the young person

This phase is signalled by steady weight gain reaching 90% of ideal weight, the young person eating without struggle or conflict and a shift in the parent’s mood to that of relief in having taken charge of the eating disorder.

The focus during this phase of treatment is to help parents gradually give their young person back control over eating once again. Hence, reaching this phase of treatment must not be rushed. The main task is still the return to physical health, however this needs to be done in a way that is sensitive to the young person’s age and the parenting style of the adults. The symptoms of the eating disorder stay central to discussions within these sessions, however other family difficulties, day to day worries of the adolescent or parenting issues which affect the parent’s ability to continue to ensure steady weight gain are brought forward during this phase.

Phase III: Establishing healthy adolescent identity

Phase III is signalled by the young person’s ability to maintain weight above 95% of ideal weight and by the assessment of both the therapist and parents that the anorexia will not return if the focus is removed from it.

There is a shift in treatment during this phase to a focus on helping the young person establish a healthy adolescent identity. That is, the issues central to adolescent development are discussed, including developing autonomy for the young person. In addition, parents are helped to form appropriate parental boundaries and are encouraged to refocus on their relationship as a couple – now that the crisis of the anorexia has been removed. Furthermore, a list of adolescent issues to be the focus of this phase is developed with the family and a separate course of individual therapy may be organised.

Lock, J., Agras, W.S., Bryson, S., and H. Kraemer. 2005. A comparison of short- and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 632-639.

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